Which precaution is most important for the nurse to teach a patient who is receiving intravenous (IV) drug therapy?
a. "Turn on your call light if the IV machine starts to beep for any reason."
b. "Do not use the arm that has the IV running in it for any reason whatsoever."
c. "Call me immediately if you start to feel any pain or burning in the arm with the IV."
d. "If you think the IV is running too slowly, just push the up-arrow button on the machine once or twice."
C
Pain and burning at the site are indicators of infiltration and extravasation. These indicators must be investigated as soon as they start to prevent tissue damage. Although it is helpful for the pa-tient to alert the nurse that the machine is beeping, it is not the most important precaution. The patient should never be told to adjust the flow rate. Depending on the specific location of the needle, the arm with the IV can be used gently.
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a. Reassure the parent the teen is exerting independence. b. Ask the parent about the teen's friends and activities. c. Assess the teen for depression and possible suicide risk. d. Refer the family to the community depression support group.
The nurse is caring for a client with a medical diagnosis of increased intracranial pressure. Which IV fluid order would the nurse accept without questioning?
1. Run normal saline at 125 mL/hour. 2. Run 5% dextrose in water at 80 mL/hour. 3. Run 5% dextrose in 0.45% NaCl at 75 mL/hour. 4. Run half-normal saline at 200 mL/hour.
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?
A) Respirations of 12 breaths/minute B) Cloudy urine C) Blood sugar 170 mg/dL D) Fruity breath